Pharmacy and Therapeutics (P&T) Committee Provider Update
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1 Pharmacy and Therapeutics (P&T) Committee Provider Update FIRST QUARTER 2017 P&T Committee Decisions effective March 1, 2017 Dear Healthcare Practitioner: The Presbyterian Health Plan, Inc., and Presbyterian Insurance Company, Inc. (Presbyterian) P&T Committee meets quarterly to promote the appropriate use of drugs, to maintain the Presbyterian formularies, and to support our network of practitioners. The P&T Committee met on January 18, 2017, and we would like to share with you the decisions made at the meeting that affect our formularies and pharmacy benefits. Formulary Additions Drug Name Centennial Care Commercial Metal Level Plans Medicare* Cayston (aztreonam for inhalation solution) 75 mg/vial Emverm (mebendazole) 100 mg chewable tablet PA, SP, QL (84 ml/56 days) Tier 4, PA, SP, QL (84 ml/56 days) Tier 4, PA, SP, QL (84 ml /56 days) (#6/21 days) Tier 5, PA Iclusig (ponatinib) 15 mg and 45 mg tablets Invokana (canagliflozin) 100 mg and 300 mg tablets (15 mg = #60/30 days, 45 mg= #30/30 days) Tier 3, PA, QL Tier 5, PA, QL (15 mg = #60/30 days, 45 mg= #30/30 days) Tier 4, ST, QL Lartruvo (olaratumab) 500 mg/50 ml solution for IV infusion Latuda (lurasidone) 20 mg, 40 mg, 60 mg, 80 mg, and 120 mg tablets leucovorin calcium injection solution, 350 mg PA, MB PA, MB PA, MB Tier 5, PA MB MB Tier 3, PA Tier 2 MB = Medical Benefit, = Non-Formulary, PA = Prior Authorization Required, QL = Quantity Limits Apply, Tier 4 (20 mg, 40 mg, 60 mg, and 80 mg) Tier 5 (120 mg) PPC P&T COMMITTEE PROVIDER UPDATE FIRST QUARTER
2 Drug Name Centennial Care Commercial Metal Level Plans Medicare* Formulary Additions (continued) octreotide acetate 200 mcg/ml injection MB MB Tier 4, PA Tier 2 Narcan (naloxone HCl nasal spray) 4mg/0.1mL Oxytrol for Women (oxybutynin transdermal) 3.9 mg/day patches paliperidone (generic for Invega ) 1.5 mg, 3 mg, 6 mg, and 9 mg extended-release tablets Formulary Tier 2 Tier 2 QL (#8/28 days) Tier 3, PA, QL (#8/28 days) Tier 4, ST, QL papaverine HCL solution 30 mg/ml Tier 3, PA Rexulti (brexpiprazole) 0.5 mg, 1 mg, 2 mg, 3 mg, and 4 mg tablets Rubraca (rucaparib) 200 mg and 300 mg tablets PA, QL ticlopidine (Ticlid ) 250 mg tablet Tier 3, PA, QL (#60 per 30 days) Ulesfia (benzyl alcohol) 5% lotion Tier 3, PA, QL Xartemis XR (oxycodone HCL and acetaminophen) 7.5 mg/325 mg extended-release tablets Tier 3, PA, QL New Generics Unless otherwise noted, when a generic becomes available, the brand name product will be removed from the formularies. abacavir/lamivudine (generic for Epzicom ) 600 mg/300 mg tablet epinephrine 0.15 mg and 0.3 mg auto-injectors (generic for EpiPen and EpiPen Jr) estradiol 10 mcg vaginal tablets (generic for Vagifem) QL Tier 1, QL Tier 1, QL P&T COMMITTEE PROVIDER UPDATE FIRST QUARTER Tier 4, ST, QL (1.5 mg, 3 mg, and 9 mg= #1/day, 6 mg= #2/day) Tier 5, PA (New Starts), QL Tier 5, PA, QL Tier 5 Formulary Tier 1 Tier 1 Tier 2 Formulary Tier 1 Tier 1 Tier 3 ezetimibe (generic for Zetia ) 10 mg tablet Formulary (brand name levalbuterol 45 mcg/actuation MDI (generic for Xopenex HFA) metoprolol succinate ER/ hydrochlorothiazide tablets (generic for Dutoprol ) - Brand removed from Centennial Care, Commercial and Metal Level Formularies. Generic product will not be added. Active ingredients are available separately and covered on all formularies. olmesartan (generic for Benicar ) 5 mg, 20 mg, and 40 mg tablets olmesartan/hydrochlorothiazide (generic for Benicar HCT) 20 mg/12.5 mg, 40 mg/12.5 mg, 40 mg/25 mg tablets mycophenolate mofetil 500 mg/20 ml IV solution (generic for CellCept IV) (brand name (brand name Tier 3, ST Tier 3, ST Tier 4, ST Tier 3 Tier 3 Tier 3, ST Tier 3 Tier 3 Tier 3, ST Tier 4, PA (B vs D) MB = Medical Benefit, = Non-Formulary, PA = Prior Authorization Required, QL = Quantity Limits Apply,
3 Drug Name Centennial Care Commercial Metal Level Plans Medicare* Other Formulary Changes: Criteria Updates, Formulary Removals, and Tier Placement Changes aripiprazole tablets (generic for Abilify ) 2 mg, 5 mg, 10 mg, 15 mg, 20 mg, and 30 mg and aripiprazole orally disintegrating tablets (generic for Abilify Disc melt ) 10 mg and 15 mg Bipolar I Disorder and Autistic Disorder prior authorization criteria revised on Centennial Care, Commercial and Metal Level Plans formularies. PA, QL Tier 4, ST, QL (2 mg, 5 mg, 10 mg, and 15 mg) Tier 5, ST, QL (10 mg and 15 mg ODT and 20 mg and 30 mg tablets) buprenorphine/naloxone sublingual tablets (generic for Suboxone ) 2 mg-0.5 mg, 8 mg-2 mg and Suboxone Film 2 mg-0.5 mg, 4 mg-1 mg, 8 mg-2 mg, and 12-3 mg tablets moved to Tier 1 on Commercial and Metal Level Plans and prior authorization removed from film and tablets. QL (#90 per 30 days) tablets= Tier 1, QL (#90/30) Film= Tier 3, QL mg, 4-1 mg, & 8-2 mg= 12-3 mg= #60/30 days tablets= Tier 1, QL (#90/30) Film= Tier 3, QL mg, 4-1 mg, & 8-2 mg= 12-3 mg= #60/30 days tablets= Tier 2, QL Film= Tier 4, QL (12 mg-3 mg is non-formulary) QVAR (beclomethasone dipropionate) inhalation aerosol Prior authorization requirement added to QVAR on Commercial and Metal Level Plan formularies. Flovent is the preferred formulary inhaled corticosteroid. ST Tier 3, PA Tier 3, PA Tier 4 Vesicare (solifenacin succinate) 5 mg and 10 mg tablets Moved from Tier 2 to Tier 3 and step therapy requirement added on Commercial and Metal Level Plan formularies. Tier 3, ST, QL Tier 3, ST, QL Tier 3, QL venlafaxine SR tablets 37.5 mg, 75 mg, 150 mg, and 225 mg Removed from Commercial and Metal Level Plan formularies. Venlafaxine SR capsules (generic for Effexor XR) are covered on all formularies. Tier 4, QL zolmitriptan tablets (Zomig ) 2.5 mg and 5 mg Moved from Tier 3 to Tier 1 on Commercial and Metal Level Plan formularies. Step therapy requirement added. Tier 1, ST, QL (#18/30 days) Tier 1, ST, QL (#18/30 days) MB = Medical Benefit, = Non-Formulary, PA = Prior Authorization Required, QL = Quantity Limits Apply, P&T COMMITTEE PROVIDER UPDATE FIRST QUARTER
4 Formulary Preferred Viscosupplement Products Euflexxa (1% sodium hyaluronate) and Gel-One (cross-linked hyaluronate) are now the formulary preferred viscosupplement products for the treatment of osteoarthritis of the knee. Prior authorization is required and these products may be obtained from a preferred specialty pharmacy. Commercial and Metal Level Plans: Coverage of Interferons for the treatment of Multiple Sclerosis Rebif (interferon beta-1a) is now the preferred formulary interferon for the treatment of multiple sclerosis on Commercial and metal level plans. Rebif requires a prior authorization for coverage and may be obtained from a preferred specialty pharmacy. Avonex (interferon beta-1a) and Extavia (interferon beta-1b) now require a trial and failure of Rebif and also may be obtained from a preferred specialty pharmacy. Coverage of Hepatitis C Treatment for Presbyterian Centennial Care There were changes to the coverage of treatment for chronic hepatitis C virus (HCV) including the following: Zepatier (elbasvir and grazoprevir) is now the preferred formulary medication for the treatment of HCV genotypes 1 and 4. In addition to other prior authorization requirements testing for NS5A resistance in genotype 1a patients is required. The New Mexico Centennial Care HCV Treatment criteria for coverage have been recently updated. Carisoprodol removal from Centennial Care, Commercial, and Metal Level Plan formularies Carisoprodol-containing medications were removed from Centennial Care, Commercial and Metal Level Plan Formularies effective January 15, Carisoprodol was removed from the formularies for safety reasons. Carisoprodol-containing medications also non-formulary on the PHP Medicare formulary and are considered to be high risk medications in patients 65 years of age and older by the Centers for Medicare and Medicaid Services (CMS). Carisoprodol quickly metabolizes to meprobamate, an anxiolytic known for its addictive potential. Carisoprodol alone or with other agents (opioids and benzodiazepines, in particular) reportedly caused more than 30,000 emergency department visits in Carisoprodol when used in combination with at least one opioid and a benzodiazepine is nicknamed the Holy Trinity because of the feeling of euphoria that it produces similar to that of heroin. When combined these drugs are synergistic in causing respiratory depression and could collectively result in death 2. There are safer alternatives to carisoprodol covered on the formularies including baclofen and tizanidine. References: 1. Deadly Drug Combinations Escaping Notice: A Health systems Report [Internet] [accessed 2014 Sept 21]. Available from: 2. J Fundin. The Perfect Storm: Opioid Risks and The Holy Trinity [Internet]. 24 September [Accessed November 7, 2016]. Available from: You can find the complete prior authorization and step therapy requirements and other information regarding Presbyterian formularies online at: P&T COMMITTEE PROVIDER UPDATE FIRST QUARTER
5 FDA Alerts from October 2016 to January 2017 For full information see the FDA website at: SafetyAlertsforHumanMedicalProducts Testosterone and Other Anabolic Androgenic Steroids (AAS) FDA Statement (10/25/2016): The FDA has approved labeling changes for all testosterone and AAS products, adding a new Warning and updating the Abuse and Dependence section to include new safety information regarding the risks associated with abuse and dependence. Reported serious adverse outcomes associated with abuse of these medications include heart attack, heart failure, stroke, depression, hostility, aggression, liver toxicity, and male infertility. Pioglitazone-containing medications Drug Safety Communication (12/12/2016): Multiple published studies have been reviewed by the FDA, and overall, the data from these studies suggested that the Type 2 diabetes medication pioglitazone may be linked to an increased risk of bladder cancer. The labels of pioglitazone containing medications (Actos, Actosplus Met, Actosplus Met XR, Duetact, and Oseni) were updated in 2011 to include warnings about this risk and the FDA has approved label changes to include information about additional studies reviewed. The FDA is recommending that pioglitazone should not be used in patients with active bladder cancer and risks/benefits should be considered prior to using in patients with a history of bladder cancer. Chantix (varenicline) and Zyban (bupropion) Drug Safety Communication (12/16/2016): Based on the results from a large clinical trial the FDA has determined that the risk of serious side effects on mood, behavior, or thinking with the smoking cessation medications Chantix and Zyban is lower than previously thought. The FDA is removing the Boxed Warning for serious mental health effects seen in patients quitting smoking from from the Chantix and Zyban labels. And the risk evaluation and mitigation strategy (REMS) that formally required the patient Medication Guide be provided with every patient prescription will be removed. The risk of these mental side effects is still present, especially in patients currently being treated for mental illnesses, but most people who had these side effects did not have serious consequences such as hospitalization. Contact Us The changes to our formularies are based on requests from our practitioners and by the recommendations of the P&T Committee. We value your input. If you have any concerns, please contact the pharmacy director, Louanne Cunico, PharmD, at lcunico@phs.org or (505) You may also contact the author of this newsletter, Kendra Ward, PharmD, at kward2@phs.org or (505) , Monday through Friday from 8 a.m. to 5 p.m. Thank you for partnering with us to improve the health of patients, members, and communities we serve. P&T COMMITTEE PROVIDER UPDATE FIRST QUARTER
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